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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197403329
Report Date: 06/27/2019
Date Signed: 06/27/2019 10:56:32 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME:CROSSWIND COMMUNITY CHURCH-ADVENTURELAND P.S.FACILITY NUMBER:
197403329
ADMINISTRATOR:JIMENEZ, MISTYFACILITY TYPE:
850
ADDRESS:41337 10TH STREET WESTTELEPHONE:
(661) 272-4903
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:73CENSUS: 40DATE:
06/27/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Misty Jimenez TIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Victoria Hunt met with Misty Jimenez, Director, for a Case Management inspection involving an Unusual Incident Report (UIR) received by telephone on 06/26/19. Upon arrival, there were 40 children and 4 staff present today for the preschool license.

Description of the incident: The incident occurred on 06/25/19 at approximately around 10:58 am in the Monkey classroom. Child #1 was running towards her teacher for a hug and child #1, tripped her her feet and fell and hit her head. This resulted in a 1 1/2 laceration on the left side of the child's forehead.

LPA interviewed staff, child in question, and reviewed facility records. At the time of the incident it appears that the staff were in ratio and capacity. The staff promptly administered aid to child #1, an ice pack was applied and the child's parent was contacted immediately. Child #1 was taken to the doctors and was released to return back to the day care the following day. Child #1 is still in attendance at this facility. Based on the information obtained, it does not appear that a violation of Title 22 Regulations occurred due to the incident being an accident.

No citations are being issued on this date. This Unusual Incident was reported timely to the Palmdale Regional Office. Director has met with staff to ensure that preventative measures are being taken to ensure the safety of children in care. To mitigate any future issues director has reviewed safety procedures and advised staff to closely monitor children in the classroom. Teachers have advised children of the dangers of running in the classroom and have reminded children the importance of walking and not running in the classrooms. An exit interview was conducted and a copy of this report was read and provided to the Assistant Director on 06/27/19.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Victoria HuntTELEPHONE: (661) 568-8930
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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